Create New Prime Admin Account

TaxId Assignment:

Tax ID

* Assigned Tax IDs

Your Personal Information:

* First Name

* Last Name

* Provider or Group Name

* Job Title

Your Contact Information:

* Email Address

* Confirm Email Address

* Business Phone

Business Ext.

* Prime Admin Account Holder Phone

Prime Admin Account Ext.

Fax 1

Fax 2

Your Mailing Information:

*Mailing Name

* Mailing/Billing Address

* Mailing/Billing Address 2

* City

* State

* Zip Code

Your Service Location Information:

*Office Name

* Service Address

* Service Address 2

* City

* State

* Zip Code

Your Login Information:

Security Question

Security Answer

Prime Admin Account Enrollment Agreement

The information provided through the Health Choice Arizona Online Web Application is confidential under state and federal law. Use and disclosure of this information is limited to purposes directly related to the business of Health Choice Arizona. The use and disclosure of this information is also subject to the privacy and security requirements of the Administrative Simplification provisions of the federal Health Insurance Portability and Accountability Act.

• The Prime Admin Account Holder is responsible for ensuring the confidentiality of any information obtained from this web application by persons using the Prime Admin Account Holder user ID or any individual user IDs approved by the Prime Admin Account Holder.

• The Prime Admin Account Holder is responsible for informing its employees of the requirements of all applicable privacy laws and ensuring compliance with the license agreement.

• Additionally, the Prime Admin account holder is required to ensure: - Individual accounts are limited to employees who need the information to perform their employment-related duties - All user IDs and passwords are protected from being shared or disclosed

Violation of the terms and conditions of the licensing agreement and/or violations of the state and federal confidentiality and privacy requirements may result in termination of your privileges to access the Health Choice Arizona Online Web Application. Violations may also result in the termination the Health Choice Arizona Provider Agreement, and/or the termination of or imposition of sanctions under any other contract or agreement with the Health Choice Arizona Administration. (If you have any questions, call the Provider Portal Coordinator at 480-760-4651 or email HCHProviderPortal@azblue.com)

* Signature of Authority
Certification: I agree in accordance with, and under the penalties of, law that I and all registered persons under this practice will not use or disclose Protected Health Information in this letter. I further agree to terminate all users under its practice upon 1 calendar day of employee separation.

CANCEL